Cost-effectiveness analysis of different embryo transfer strategies in England

Outcomes of frozen embryo transfer in patients with and without ovarian hyperstimulation syndrome

"Introduction: One of the methods utilized to treat infertility is the use of frozen embryos. This technique is particularly employed in patients with ovarian hyperstimulation syndrome (OHSS), which leads to heightened blood estrogen levels. The purpose of this study was to compare the percentage of pregnancy and abortion between patients who used the frozen embryo method due to OHSS and others who practiced the same method for other reasons. Materials and Methods: This retrospective, cohort study was conducted on a total of 338 patients who visited in vitro fertilization (IVF) section of Kowsar Hospital of Urmia-Iran to employ the frozen embryo method (May 2013 to December 2015). The patients were classified into two groups, i.e. the OHSS group (N=150) and the non-OHSS group (N=188). Data were obtained and examined by evaluating the files in a questionnaire. Results: The two groups did not differ significantly with regard to their mean age (p = 0.57). There was also no statistically significant difference between the OHSS and non-OHSS groups regarding the quality of frozen embryo transferred (P = 0.17). Also, there was also no statistically significant difference between the two groups in terms of their pregnancy rate (OHSS = 30.0% vs. non-OHSS = 25.0%) and miscarriage rate (OHSS = 31.11% vs. non-OHSS = 24.44%) (p = 0.32 and p = 0.31, respectively). Conclusion: Ovum exposure to high estrogen during ovulation stimulation does not affect embryo implantation and miscarriage in patients with OHSS."

Modelling futility in the setting of fertility treatment

When is a fertility treatment futile? This question has great practical importance, given the role futility plays in ethical, legal and clinical discussions. Here, we outline a novel method of determining futility for IVF treatments. Our approach is distinctive for considering the economic value attached to the intended aim of IVF treatments, i.e. the birth of a child, rather than just the effects on prospective parents and the health system in general. We draw on the commonly used metric, quality-adjusted life years (QALYs), to attach a monetary value to new lives created through IVF. We then define futility as treatments in which the chance of achieving a live birth is so low that IVF is no longer a cost-effective intervention given the economic value of new births. This model indicates that IVF treatments in which the chance of a live birth are <0.3% are futile. This suggests IVF becomes futile when women are aged between 47 and 49 years of age. This is notable older than ages currently considered as futile in an Australian context (∼45). In the UK, government subsidized treatment with the couple's own gametes stops at the age of 42, while privately funded treatments are self-regulated by individual providers. In most European countries and the USA, the 'age of futility' is likewise managed by clinical consensus.

Single Embryo Transfer Versus Double Embryo Transfer: A Cost-Effectiveness Analysis in a Non-IVF Insurance Mandated System

INTRODUCTION

Because of increased morbidity seen in multiple gestations, the American Society of Reproductive Medicine recommends transfer of blastocysts one at a time for most patients. While cost-effectiveness models have compared single embryo transfer (SET) versus double embryo transfer (DET), few incorporate maternal and neonatal morbidity, and none have been performed in U.S. Military facilities. The purpose of this study was to determine the cost effectiveness of sequential SET versus DET in a U.S. Military treatment facility.

MATERIALS AND METHODS

A cost-effectiveness model was created based on 250 patients between the ages of 20-44 who previously underwent in vitro fertilization (IVF) at our facility. The model consisted of patients pursuing either SET or DET with two total embryos. Cycle outcomes were determined using the published SARTCORS success calculator. Neonatal and obstetrical outcomes were simulated based on singleton and twin IVF pregnancies. Neonatal and obstetrical cost estimates were based on internal data as well.

RESULTS

If 250 model patients pursue SET, 140 live births would occur, with total cost of $5.7 million, and cost per delivery of $40,500. If the model patients pursued DET, 117 live births would occur, with total cost of $9.2 million and a cost per delivery of $77.700. DET would lead to more total infants (207 vs. 143 in SET cohort). Personal costs are higher in SET versus DET cohorts ($23,036 vs. $20,535).

CONCLUSIONS

SET in a system with no infertility coverage saves approximately $3.5 million per 250 patients. Higher personal costs as seen with SET may incentivize patients to seek DET. The total savings should encourage alteration to practice patterns with the U.S Military Healthcare System.

A study on the effectiveness of clomiphene citrate in comparison to GnRH antagonist in preventing LH surge among patients undergoing ovulation induction in IVF-ICSI

Abstract: Objective: To determine the efficacy of clomiphene citrate (CC) in preventing luteinizing hormone (LH) surge without adding gonadotropin releasing hormone (GnRH) antagonist or GnRH agonist in stimulated first fresh intracytoplasmic sperm injection cycle by evaluating the outcome of oocytes and embryo quality. Design: Registry cohort study. Settings: Fertility Clinic Registry at Hospital University Kebangsaan Malaysia. Patients: A total of 235 fresh stimulated ICSI cycle for patients aged 18-40 years old using clomiphene citrate plus gonadotropin (n = 117) and GnRH antagonist plus gonadotropin (n = 118) were studied. Intervention: Comparing two different ovarian stimulation protocol. Main outcome measure(s): Social economical demographic, ovarian stimulation response and laboratory outcome. Fertilization rate as our primary outcome and our secondary outcome were oocyte retrieval rate, mature oocyte rate and top quality embryo rate. Result(s):There were no difference in the demographic and hormonal characteristic of the study groups. The primary outcome of fertilization rate has significant difference with p value of 0.003; 73.2% for CC group and 64.2% for GnRH antagonist group. The secondary outcome of OR rate (78.4% ± 17.6% VS 80.3% ± 13.4%, p = 0.368), mature oocyte rate (85.2% ± 19.0 VS 81.7% ± 16.7%, p = 0.130) and top quality embryo rate (79.4% ± 24.2% VS 74.9% ± 22.9%, p = 0.178) were comparable between both groups. There were significant difference between the endometrial thickness on the day of trigger and OHSS risk among both groups (8.5 mm ± 1.0 mm VS 9.4 mm ± 1.1 mm, p < 0.001 and 12.8% VS 44.1% respectively). Discussion: Minimal stimulation protocol with CC and gonadotropin may be the answer to many infertile couples in need of IVF and yet having financial situation deterring them in attempting IVF treatment. GnRH antagonist could be safely replaced by CC by extending to 10 days as this protocol gives better primary outcome and comparable secondary outcomes with less OHSS. CC is recognized to induce thinning of endometrial lining and thus, may impair embryo implantation. However, with advancement of the vitrification system and higher success rate in frozen-thaw embryo transfer worldwide provides an excellent solution for this issue.

Cost-effectiveness of single versus double embryo transfer in IVF in relation to female age

OBJECTIVE

To evaluate the cost-effectiveness of single embryo transfer followed by an additional frozen-thawed single embryo transfer, if more embryos are available, as compared to double embryo transfer in relation to female age.

STUDY DESIGN

We used a decision tree model to evaluate the costs from a healthcare provider perspective and the pregnancy rates of two embryo transfer policies: one fresh single embryo transfer followed by an additional frozen-thawed single embryo transfer, if more embryos are available (strategy I), and double embryo transfer (strategy II). The analysis was performed on an intention-to-treat basis. Sensitivity analyses were carried out to evaluate the robustness of our model and to identify which model parameters had the strongest impact on the results.

RESULTS

SET followed by an additional frozen-thawed single embryo transfer if available was dominant, less costly and more effective, over DET in women under 32 years. In women aged 32 or older DET was more effective than SET followed by an additional frozen-thawed single embryo transfer if available but also more costly.

CONCLUSION

SET followed by an additional frozen-thawed single embryo transfer should be the preferred strategy in women under 32 undergoing IVF. The choice for SET followed by an additional frozen-thawed single embryo transfer or DET in women aged 32 or older depends on individual patient preferences and on how much society is willing to pay for an extra child. There is a strong need for a randomized clinical trial comparing the cost and effects of SET followed by an additional frozen-thawed single embryo transfer and DET in the latter category of women.

Cost-effectiveness of embryo transfer strategies: a decision analytic model using long-term costs and consequences of singletons and multiples born as a consequence of IVF

STUDY QUESTION

What is the cost-effectiveness of elective single embryo transfer (eSET) versus double embryo transfer (DET) strategies from a societal perspective, when applying a time horizon of 1, 5 and 18 years?

SUMMARY ANSWER

From a short-term perspective (1 year) it is cost-effective to replace DET with single embryo transfer; however when intermediate- (5 years) and long-term (18 years) costs and consequences are incorporated, DET becomes the most cost-effective strategy, given a ceiling ratio of €20 000 per quality-adjusted life years (QALY) gained.

WHAT IS ALREADY KNOWN

According to previous cost-effectiveness research into embryo transfer strategies, DET is considered cost-effective if society is willing to pay around €20 000 for an extra live birth. However, interpretation of those studies is complicated, as those studies fail to incorporate long-term costs and outcomes and used live birth as a measure of effectiveness instead of QALYs. With this outcome, both multiple and singletons were valued as one live birth, whereas costs of all children of a multiple were incorporated.

STUDY DESIGN, SIZE, DURATION

A Markov model (cycle length: 1 year; time horizon: 1, 5 and 18 years) was developed comparing a maximum of: (i) three cycles of eSET in all patients; (ii) four cycles of eSET in all patients; (iii) five cycles of eSET in all patients; (iv) three cycles of standard treatment policy (STP), i.e. eSET in women <38 years with a good quality embryo, and DET in all other women; and (v) three cycles of DET in all patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Expected life years (LYs), child QALYs and costs were estimated for all comparators. Input parameters were derived from a retrospective cohort study, in which hospital resource data were collected (n=580) and a parental questionnaire was sent out (431 respondents). Probabilistic sensitivity analysis (5000 iterations) was performed.

MAIN RESULTS AND THE ROLE OF CHANCE

With a time horizon of 18 years, DETx3 is most effective (0.54 live births, 10.2 LYs and 9.8 QALYs) and expensive (€37 871) per couple starting IVF. Three cycles of eSET are least effective (0.43 live births, 7.1 LYs and 6.8 QALYs) and expensive (€25 563). We assumed that society is willing to pay €20 000 per QALY gained. With a time horizon of 1 year, eSETx3 was the most cost-effective embryo transfer strategy with a probability of being cost-effective of 99.9%. With a time horizon of 5 or 18 years, DETx3 was most cost-effective, with probabilities of being cost-effective of 77.3 and 93.2%, respectively.

LIMITATIONS, REASONS FOR CAUTION

This is the first study to use QALYs generated by the children in the economic evaluation of embryo transfer strategies. There remains some disagreement on whether QALYs generated by new life should be used in economic evaluations of fertility treatment. A further limitation is that treatment ends when it results in live birth and that only child QALYs were considered as measure of effectiveness. The results for the time horizon of 18 years might be less solid, as the data beyond the age of 8 years are based on extrapolation.

WIDER IMPLICATIONS OF THE FINDINGS

The current Markov model indicates that when child QALYs are used as measure of outcome it is not cost-effective on the long term to replace DET with single embryo transfer strategies. However, for a balanced approach, a family-planning perspective would be preferable, including additional treatment cycles for couples who wish to have another child. Furthermore, the analysis should be extended to include QALYs of family members.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by a research grant (grant number 80-82310-98-09094) from the Netherlands Organization for Health Research and Development (ZonMw). There are no conflicts of interest in connection with this article.

TRIAL REGISTRATION NUMBER

Not applicable.

Cumulative live birth rate after two single frozen embryo transfers (eSFET) versus a double frozen embryo transfer (DFET) with cleavage stage embryos: a retrospective cohort study

PURPOSE

According to the latest ART report for Europe, about 13% of pregnancies after frozen embryo transfer are multiple. Our objective was to analyse the impact on the multiple pregnancy rate of two eSFET (elective single frozen embryo transfers) versus a DFET (double frozen embryo transfer) in women aged under 38 years, who had not achieved pregnancy in their fresh transfer and who had at least two vitrified embryos of A/B quality.

METHODS

This study was conducted from January 2010 to June 2013 at a public hospital. The couples were divided into three groups. Group DFET: the first cryotransfer of two embryos (105 women); cSFET group: the only cryotransfer of a single vitrified embryo (60 women); eSFET group, individually vitrified embryos: 20 patients included in a clinical trial of single-embryo fresh and frozen transfer and 21 patients who chose to receive eSFET.

RESULTS

The clinical pregnancy rate was 38.1% in the DET group and the cumulative clinical pregnancy rate was 43.3% in the eSFET group. There were no significant differences between the DFET and eSFET groups (30.0 vs 34.1%) in cumulative live birth delivery rate. The rate of multiple pregnancies varied significantly between the DFET and eSFET groups (32.5 vs 0%, p < 0.05).

CONCLUSIONS

For good-prognosis women aged under 38 years, taking embryo quality as a criterion for inclusion, an eSFET policy can be applied, achieving acceptable cumulative clinical pregnancy and live birth rates and reducing multiple pregnancy rates.

The economic implications of multiple pregnancy following ART

The clinical risks to mothers and babies associated with assisted reproductive technology (ART) multiple birth pregnancies are well described and widely recognized. In contrast, the long-term economic consequences that follow are less appreciated. The few economic analyses that do exist consistently demonstrate the greater patient, healthcare and societal costs associated with twins and higher-order multiples when compared with singleton infants, and convincingly add to the argument that single embryo transfer should be standard practice in most patient groups. Several recent studies have shown that the relative price paid by patients for ART treatment not only has implications for who can afford to access treatment, but also plays an important role in incentivizing embryo transfer practices and thus ART multiple birth rates. This review summarizes the current literature on the costs and consequences of ART multiple births, the contribution of ART multiple births to the economic burden associated with preterm birth, the evidence for the cost-effectiveness of single embryo transfer, and the association between the cost of treatment and the downstream costs associated with multiple births.

Direct health services costs of providing assisted reproduction services in older women

OBJECTIVE

To assess the total health service costs incurred for each live birth achieved by older women undergoing IVF compared with costs in younger women.

DESIGN

Retrospective cross-sectional analysis.

SETTING

In vitro fertilization unit and maternity hospital in a tertiary care setting.

PATIENT(S)

Women who underwent their first cycle of IVF between 1997 and 2006.

INTERVENTION(S)

Bottom-up costs were calculated for all interventions in the IVF cycle. Early pregnancy and antenatal care costs were obtained from National Health Service reference costs, Information Services Division Scotland, and local departmental costs.

MAIN OUTCOME MEASURE(S)

Cost per live birth.

RESULT(S)

The mean cost per live birth (95% confidence interval [CI]) in women undergoing IVF at the age of > or =40 years was pound 40,320 (pound 27,105- pound 65,036), which is >2.5 times higher than those aged 35-39 years (pound 17,096 [pound 15,635- pound 18,937]). The cost per ongoing pregnancy was almost three times in women aged > or =40 (pound 31,642 [pound 21,241- pound 58,979]) compared with women 35-39 years of age (pound 11,300 [pound 10,006- pound 12,938]).

CONCLUSION(S)

The cost of a live birth after IVF rises significantly at the age of 40 years owing to lower success rates. Most of the extra cost is due to the low success of IVF treatment, but some of it is due to higher rates of early pregnancy loss.